Chapter 36 Nursing Fundamental Course Point

The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

confused to time and place

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

reviewing and revising the pain management treatment plan

A nurse is caring for a client who was administered an opioid. The client reports constipation. What is another potential side effect of opioid use?

sedation

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?

"Can you describe the type of pain you are having?"

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?

"How long have you experienced this pain?"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body."

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense."

Which client statements would indicate to the nurse that the client needs additional teaching regarding prn pain medication and management? Select all that apply.

"I should wait until my pain gets worse before asking for pain medications." "It's better to put up with the pain than deal with side effects of medication." "If I ask for pain medication, I may become addicted." "The nurse will know when my medication is due and will give it to me automatically."

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

Two hours after receiving a pain medication, the client reports still suffering from pain. Which response is most appropriate?

"Tell me more about your pain."

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed with safeguards to limit the possibility overmedication."

A client has just been started on opioid analgesia for pain control. The nurse assesses the client's level of sedation using a sedation scale and notes that the client is awake and alert. The nurse would assign which rating?

1

A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation. What would be the sedation score for this client?

3

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle

he nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle

A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique?

A nurse applies intermittent heat and cold to a client's leg.

A sudden blow to the head results in pain that is transmitted by which type of fibers?

A-delta

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?

Acknowledge the pain as the client reports it and administer pain medication as prescribed.

The client had orthopedic surgery 2 days ago. Physical therapy is scheduled in 1 hour. During the nurse's rounds, the client reports postoperative pain as mild and denies needing the prescribed oral pain medication. Which nursing action will best aid in mobilizing the client?

Adding the use of hot or cold packs for pain control

The nurse is caring for a client with chronic back pain due to inoperable spinal stenosis. Which strategies, suggested by the nurse, may help to decrease the client's back pain?

Adding the use of hot or cold packs for pain control

A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action?

Administer a nonopioid medication

A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?

Administer naloxone

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?

Administration of 0.4 mg of naloxone

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation?

Ask the boy to draw a cartoon about the color or shape of his pain.

The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment?

Assess for nonverbal cues to pain

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action?

Avoid massaging this area and report the finding to the health care provider.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

CRIES Pain Scale

The nurse is reviewing relaxation techniques with the client who has chronic back pain that radiates to the legs. What information does the nurse include?

Close your eyes while practicing the relaxation exercises.

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention?

Closing the client's room door to reduce unnecessary noises

What type of pain will the client experience as a result of the intervention being preformed?

Cutaneous

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

Cutaneous stimulation

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding.

How should the nurse position the head of the bed for a client receiving epidural opioids?

Elevated 30 degrees

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.)

Encourage deep breathing. Play the client's favorite music. Promote a restful environment.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

Which of the following is considered to be the most potent neuromodulators?

Endorphins

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

Guarding of the chest area

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

Naloxone

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?

PRN order

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

The nurse is performing an assessment of a client that is experiencing pain after a surgical procedure. What symptoms does the nurse assess based on the pain response?

Pupils are dilated.

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?

Preventing constipation

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?

Respiratory status, oxygen saturation, pain, and sedation level

A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action?

Start with the lowest intensity and gradually increase it to the appropriate level.

When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action?

Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?

The client is actively involved in pain management.

The nurse is conducting a pain assessment with an older adult client. The nurse notices that the client grimaces when the nurse asks the client to lean forward. The client, however, rates pain as 3 out of 10 on the numerical pain rating scale. The nurse recognizes that the client may be reporting pain inaccurately for which reason(s)? Select all that apply.

The client is concerned about being perceived as weak or bothersome. The client believes that pain is a normal part of the aging process. The client has a fear of becoming addicted to pain medications. The client is doubtful that any interventions will be helpful.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset.

A nurse is preparing to give a client a massage. What action should the nurse perform during this intervention?

Using a light, gliding stroke, apply lotion to the client's shoulders, back, and sacral area.

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?

When obtaining client vital signs

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should:

actively solicit information about the client's pain level.

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback.

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

A client comes to the facility reporting acute pain. When assessing the client, the nurse understands that moderate, superficial acute pain can result in which sympathetic physiologic response(s)? Select all that apply.

increased blood pressure increased pulse increased respiratory rate

A nurse is caring for a client whose injured cells are releasing chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

transduction

The nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision?

verbal report

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

visceral pain.